Provider Demographics
NPI:1265570469
Name:KELSO, THOMAS B II (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:B
Last Name:KELSO
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3038
Mailing Address - Country:US
Mailing Address - Phone:910-457-4789
Mailing Address - Fax:910-579-4589
Practice Address - Street 1:902 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3038
Practice Address - Country:US
Practice Address - Phone:910-457-4789
Practice Address - Fax:910-579-4589
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120032207X00000X
NC200300626207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204883003Medicaid
MO120013230Medicare PIN
NCNC9031B704Medicare PIN
MOH12626Medicare UPIN
MO262013268Medicare PIN
MO98510OtherAR BS #
AR140059001Medicaid